Provider Demographics
NPI:1497295679
Name:SKK DENTAL PLLC DBA LIBERTY DENTAL ARTS
Entity Type:Organization
Organization Name:SKK DENTAL PLLC DBA LIBERTY DENTAL ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:K
Authorized Official - Last Name:KHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-434-2090
Mailing Address - Street 1:2749 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3038
Mailing Address - Country:US
Mailing Address - Phone:585-343-2090
Mailing Address - Fax:
Practice Address - Street 1:2749 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-3038
Practice Address - Country:US
Practice Address - Phone:585-343-2090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty